- Keep a copy for yourself.
- Hand deliver and ask for a date stamp or send with Return Receipt to establish timeline or email as an attachment.
(City, State, Zip Code)
(Daytime Telephone Number / Email)
(Title – i.e. Director of Student Services / District 504 Coordinator)
(District Office or School Address)
(City, State, Zip)
Regarding: Evaluation for an IEP & 504 Plan
Student Name: ( )
Date of Birth: ( )
Name of School: ( )
Grade: ( )
I am the parent of (student’s name), who is currently enrolled at the (school name) in the (number) grade. My child has not been doing well in school, and I am concerned about his/her/their educational progress. Therefore, I request that the school district evaluate (him/her/them) for special education services.
(Student’s name) has been diagnosed with (diagnosis/es), which directly impacts (his/her/their) educational performance and needs. Though the teachers have attempted to address some areas of concern, (student’s name) continues to have difficulties, as many of the interventions have been unsuccessful.
I request a special education assessment for an IEP under 5 CCR Sec. 3021(a). (He/She/They) may be eligible for special education assistance. I am requesting (Name) be given a comprehensive assessment including but not limited to the areas (remove following areas to be assessed as necessary) of social /emotional, academic, recreational therapy, behavioral, occupational therapy, sensory integration, speech, psycho-educational, adaptive physical education.
(Include, if you do not currently have a 504 and would like the district to you asses for it too.) As part of the assessment process, I also request my child be assessed under Section 504 of the Rehabilitation Act of 1973 to determine whether (he/she/they) should be identified as “handicapped” pursuant to that law and to determine what, if any, accommodations might be required in (his/her/their) educational program if ( student’s name) does not qualify for special education services or in addition to special education services.
Thank you in advance for your collaborative efforts to provide our (student’s name) with an appropriate education. If you have any questions, please feel free to contact me. Thank you.
cc: (your child’s teacher) and/or (other staff if applicable)
- Sample Letter – Section 504 Determination Request
- Sample Letter – Request to an Evaluation for an IEP & 504 Plan
- Sample Letter – Request for Prior Written Notice – PWN
- Sample Letters – Notification of Illness from School Nurse
Learn more about PANS PANDAS in the school setting. PANS PANDAS is a medical condition in which symptoms affect a student’s ability to attend school and learn.
Written in conjunction with Shara Virlan who has 14 years of classroom education. She also has a child with PANDAS. She runs the PANS PANDAS Education Facebook page.
- S Elementary Ed. with a minor in Early Childhood ED.
- Masters in Educational Leadership
- License in Reading Instruction
- 14 years of teaching experience (Grades K-3)
- 1 year of Literacy Coaching